What is the initial approach to managing cirrhosis (scarring of the liver)?

Initial Management of Cirrhosis

The initial approach to managing cirrhosis should focus on identifying and treating the underlying cause while simultaneously preventing disease progression and addressing complications through a comprehensive strategy that includes medication, lifestyle modifications, and regular monitoring to improve survival and quality of life. 1

Addressing the Underlying Etiology

• Complete cessation of alcohol consumption is essential for patients with alcoholic cirrhosis, as this may lead to "re-compensation" and improved long-term outcomes 2, 1
• For viral hepatitis-related cirrhosis, appropriate antiviral therapy should be initiated:
  • HBV treatment with antivirals improves outcomes in some patients 2, 1
  • HCV treatment with direct-acting antivirals can improve liver function and reduce portal hypertension 2, 1
• Treatment effectiveness varies based on disease severity at the time of intervention, with better outcomes generally seen in earlier stages 2, 3

Management of Ascites

• First-line treatment for patients with cirrhosis and ascites consists of sodium restriction (88 mmol/day [2000 mg/day]) and diuretics (oral spironolactone with or without oral furosemide) 2
• For patients with tense ascites, an initial therapeutic abdominal paracentesis should be performed, followed by sodium restriction and oral diuretics 2
• Fluid restriction is not necessary unless serum sodium is less than 120-125 mmol/L 2
• For refractory ascites (unresponsive to high-dose diuretic treatment of 400 mg/day spironolactone and 160 mg/day furosemide), options include:
  • Serial therapeutic paracenteses with albumin replacement 2, 1
  • Liver transplantation evaluation 2
  • Transjugular intrahepatic portasystemic stent-shunt (TIPS) 2

Prevention of Further Decompensation

• Non-selective beta-blockers (carvedilol or propranolol) should be considered to reduce the risk of decompensation or death 4
• Avoid prostaglandin inhibitors such as NSAIDs as they can reduce urinary sodium excretion and induce azotemia 2
• Enoxaparin may delay hepatic decompensation and improve survival in some patients with cirrhosis 2, 1

Surveillance for Hepatocellular Carcinoma

• Six-monthly abdominal ultrasound assessments in combination with serum AFP estimation should be performed for surveillance in high-risk groups 2
• High-risk groups include patients with cirrhosis due to:
  • Hepatitis B virus (HBV), particularly those with ongoing viral replication 2
  • Hepatitis C virus (HCV) 2
  • Genetic hemochromatosis 2
  • Males with alcohol-related cirrhosis who are abstinent 2
  • Males with cirrhosis due to primary biliary cirrhosis 2

Management of Other Complications

• For hepatic encephalopathy, lactulose is the first-line treatment, which has been shown to reduce mortality compared to placebo 4
• For spontaneous bacterial peritonitis, antibiotic prophylaxis should be considered in high-risk patients 1
• Early identification and management of renal dysfunction is crucial to prevent hepatorenal syndrome 1

Follow-up and Monitoring

• Clinical assessment with laboratory tests and calculation of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores should occur every 6 months 3
• Liver transplantation evaluation is indicated for patients with:
  • MELD score of 15 or greater 3
  • Complications of cirrhosis 3
  • Hepatocellular carcinoma 2, 3

Common Pitfalls and Caveats

• Failure to identify and address the underlying cause of cirrhosis can lead to continued disease progression despite symptomatic management 2, 1
• Delayed recognition of complications can result in increased morbidity and mortality 4
• NSAIDs should be avoided as they can convert patients from diuretic-sensitive to refractory and should be avoided 2
• Not all patients with decompensated cirrhosis will improve with treatment of the underlying cause; response depends on disease severity at the time of intervention 2